Therapeutic validity and effectiveness of exercise interventions after lower limb-salvage surgery for sarcoma: a systematic review.

BACKGROUND: An increasing number of patients are surviving sarcoma after lower limb-salvage surgery (LSS) and are left with functional limitations. This systematic review aimed to determine the therapeutic validity and effectiveness of exercise interventions after lower limb-salvage surgery (LSS) for sarcoma. METHODS: A systematic review was conducted using formal narrative synthesis of intervention studies (with and without control group) identified through PubMed, Embase, Cochrane Library, CINAHL, and PEDro databases. Studies were included if participants were treated with LSS for unilateral lower limb sarcoma and followed an exercise intervention using active exercise, physical training, or rehabilitation before and/or after surgery. This review's outcome measures were interventions' therapeutic validity, assessed using the CONTENT scale (0 to 9); methodological quality, identified using the Downs & Black checklist (0 to 28); interventions' effectiveness, assessed based on differences in outcome measures between intervention and control groups; and certainty of evidence, classified according to the GRADE approach. RESULTS: Seven studies involving 214 participants were included. None of the included interventions were therapeutically valid (median 5, range 1-5). All but one study were of at least fair methodological quality (median 18, range 14-21). There was very low-quality evidence that exercise interventions resulted in increased knee range of motion (MD 10-15°) or compliance (MD 30%), and reduced functionality scores (MD -5%) compared to usual care. CONCLUSIONS: We found overall low therapeutic validity of interventions, performed in overall low-quality studies. Combined with the very low certainty of evidence, the results prevent drawing valid conclusions on the interventions' effectiveness. Future studies should aim for uniformity among their methodological approaches and outcome measures, using the CONTENT scale as a template to avert insufficient reporting. TRIAL REGISTRATION: PROSPERO CRD42021244635.

A protocol for periprosthetic joint infections from the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands.

Periprosthetic joint infection (PJI) is a devastating complication of joint arthroplasty surgery. Treatment success depends on accurate diagnostics, adequate surgical experience and interdisciplinary consultation between orthopedic surgeons, plastic surgeons, infectious disease specialists and medical microbiologists. For this purpose, we initiated the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands in 2014. The establishment of a mutual diagnostic and treatment protocol for PJI in our region has enabled mutual understanding, has supported agreement on how to treat specific patients, and has led to clarity for smaller hospitals in our region for when to refer patients without jeopardizing important initial treatment locally. Furthermore, a mutual PJI patient database has enabled the improvement of our protocol, based on medicine-based evidence from our scientific data. In this paper we describe our NINJA protocol.Level of evidence: III.

Time to positivity of acute and chronic periprosthetic joint infection cultures.

INTRODUCTION: A prolonged incubation time is generally recommended for diagnosing periprosthetic joint infections (PJI). However, in literature, no distinction is made between acute and chronic infections. METHODS: All patients with a PJI that underwent surgical debridement between November 2015 and February 2019 with or without revision of the prosthesis were retrospectively evaluated. Synovial fluid, 5 intraoperative periprosthetic tissue samples, and the sonicated prosthesis were cultured. RESULTS: Fifty-nine patients were analyzed, including 21 acute PJIs (33 isolates) and 38 chronic PJIs (46 isolates). In acute PJIs, all isolates grew within 5 days, while this took 11 days for chronic PJIs. Sonication fluid showed the shortest time to positivity (78% at day 2) for chronic PJIs, but no difference was observed for acute PJIs compared to tissue cultures. CONCLUSION: In contrast to cultures from chronic PJIs, acute PJIs do not need a prolonged incubation time and no clear benefit is observed for sonication.

Computer-assisted surgery compared to fluoroscopy in curettage of atypical cartilaginous tumors / chondrosarcoma grade 1 in the long bones.

INTRODUCTION: Fluoroscopy is currently the standard imaging modality for curettage of atypical cartilaginous tumors/chondrosarcoma grade 1 (ACT/CS1). Computer-assisted surgery (CAS) is a possible alternative, offering higher resolution imaging and continuous three-dimensional feedback without ionizing radiation use. CAS hypothetically makes curettage more accurate, thereby decreasing residue or recurrence rate. This study aims to compare CAS and fluoroscopy in curettage of ACT/CS1. PATIENTS AND METHODS: A single center retrospective cohort study was performed. CAS and fluoroscopy were used in parallel. Included were patients who had curettage for ACT/CS1in the long bones, with a minimum follow-up of 24 months. Tumor volume was determined on pre-operative MRI scans. Outcome comprised local recurrence rates, residue rates, complications and procedure time. RESULTS: Seventy-seven patients were included, 17 in the CAS cohort, 60 in the fluoroscopy cohort. Tumor volume was significantly larger in the CAS cohort (p = 0.04). There were no recurrences in either group. Residual tumor (2/17 vs. 7/60), complications did not differ significantly: fracture rate (3/17 vs. 6/60); nor did surgical time (1.26h vs. 1.34h). DISCUSSION: CAS curettage showed good oncologic results. Outcome was comparable to fluoroscopy, while not using ionizing radiation. There was no significant difference in surgical time. Residue rates can likely be decreased with specific software functions and surgical tools.

Diagnostic strategies for posttraumatic osteomyelitis: a survey amongst Dutch medical specialists demonstrates the need for a consensus protocol.

INTRODUCTION: Posttraumatic osteomyelitis (PTO) is a feared complication after surgical fracture care. Late diagnosis can result in interrupted and prolonged rehabilitation programmes, inability to work, medical dependency, unnecessary hospital admissions, and high medical and non-medical costs. Primary aim of this study was to assess preferred diagnostic imaging strategies for diagnosing PTO amongst orthopaedic and trauma surgeons, radiologists, and nuclear medicine physicians. Secondary aims were to determine the preferred serum inflammatory marker for diagnosing PTO and the existence of a local hospital protocol to diagnose and manage PTO. MATERIALS AND METHODS: This study utilised an online survey based on four clinical scenarios, varying from early to late onset of PTO. It was designed to assess individual practitioners' current preferred diagnostic strategy for diagnosing PTO. Eligible study participants were medical specialists and registrars in orthopaedic and trauma surgery, musculoskeletal (MSK) radiology, and nuclear medicine. RESULTS: There were 346 responders: 155 trauma surgeons, 102 orthopaedic surgeons, 57 nuclear medicine physicians, and 33 MSK radiologists. Trauma surgeons favour FDG-PET to image PTO, while orthopaedic surgeons prefer WBC scintigraphy. A similar difference was seen between radiologists and nuclear medicine physicians (MRI versus nuclear medicine imaging). CRP was regarded as the most useful serum inflammatory marker. Only one-third of all responders was aware of a local hospital protocol for the treatment of osteomyelitis. CONCLUSIONS: The availability of and awareness towards local protocols to diagnose and treat PTO is poor. The results of this study support the need for future randomised controlled trials on optimal diagnostic strategies for PTO.

Synovial calprotectin: a potential biomarker to exclude a prosthetic joint infection.

AIMS: Recently, several synovial biomarkers have been introduced into the algorithm for the diagnosis of a prosthetic joint infection (PJI). Alpha defensin is a promising biomarker, with a high sensitivity and specificity, but it is expensive. Calprotectin is a protein that is present in the cytoplasm of neutrophils, is released upon neutrophil activation and exhibits anti-microbial activity. Our aim, in this study, was to determine the diagnostic potential of synovial calprotectin in the diagnosis of a PJI. PATIENTS AND METHODS: In this pilot study, we prospectively collected synovial fluid from the hip, knee, shoulder and elbow of 19 patients with a proven PJI and from a control group of 42 patients who underwent revision surgery without a PJI. PJI was diagnosed according to the current diagnostic criteria of the Musculoskeletal Infection Society. Synovial fluid was centrifuged and the supernatant was used to measure the level of calprotectin after applying a lateral flow immunoassay. RESULTS: The median synovial calprotectin level was 991 mg/L (interquartile range (IQR) 154 to 1787) in those with a PJI and 11 mg/L (IQR 3 to 29) in the control group (p < 0.0001). Using a cut-off value of 50 mg/L, this level showed an excellent diagnostic accuracy, with an area under the curve of 0.94. The overall sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) was 89%, 90%, 81% and 95% respectively. The NPV was 97% in the nine patients with a chronic PJI. CONCLUSION: Synovial calprotectin may be a valuable biomarker in the diagnosis of a PJI, especially in the exclusion of an infection. With a lateral flow immunoassay, a relatively rapid quantitative diagnosis can be made. The measurement is cheap and is easy to use. Cite this article: Bone Joint J 2017;99-B:660-5.

The presentation, treatment and outcome of periosteal chondrosarcoma in the Netherlands.

In this case study, we describe the clinical presentation and treatment of 36 patients with periosteal chondrosarcoma collected over a 59-year period by the archive of the Netherlands Committee on Bone Tumours. The demographics, clinical presentation, radiological features, treatment and follow-up are presented with the size, location, the histological grading of the tumour and the survival. We found a slight predominance of men (61%), and a predilection for the distal femur (33%) and proximal humerus (33%). The metaphysis was the most common site (47%) and the most common presentation was with pain (44%). Half the tumours were classified histologically as grade 1. Pulmonary metastases were reported in one patient after an intra-lesional resection. A second patient died from local recurrence and possible pulmonary and skin metastases after an incomplete resection. It is clearly important to make the diagnosis appropriately because an incomplete resection may result in local recurrence and metastatic spread. Staging for metastatic disease is recommended in grade II or III lesions. These patients should be managed with a contrast-enhanced MRI of the tumour and histological confirmation by biopsy, followed by en-bloc excision.

The effect of a Galeazzi fracture on the strength of pronation and supination two years after surgical treatment.

The aim of this study was to determine the effect of a Galeazzi fracture on the strength of pronation and supination at a mean of two years after surgical treatment. The strength of pronation and supination was measured in varying rotational positions of the forearm of ten male patients (mean age 38.9 years (21 to 64)) who had undergone plate fixation for a Galeazzi fracture. The stability of the distal radioulnar joint was assessed, and a clinical assessment using the quick-Disabilities of the Arm Shoulder and Hand (quickDASH) questionnaire and patient-related wrist examination (PRWE) scores was undertaken. In addition, the strength of pronation and supination was measured in a male control group of 42 healthy volunteers (mean age 21.8 years (18 to 37)). The mean absolute loss of strength of supination in the injured compared with the non-injured arm throughout all ranges of forearm rotation was 16.1 kg (sem 5.3), corresponding to a relative loss of 12.5% (95% confidence interval (CI) 3.6 to 21.4). For the strength of pronation, the mean loss was 19.1 kg (sem 4.5), corresponding to a relative loss of 27.2% (95% CI 14.2 to 40.1). Loss of strength of supination following a Galeazzi fracture correlated with poor quickDASH (p = 0.03) and PRWE scores (p < 0.01). Loss of strength of pronation (27.2%), and of supination (12.5%) in particular, after a Galeazzi fracture is associated with worse clinical scores, highlighting the importance of supination of the forearm in function of the upper limb.

Prolonged clinical benefit from joint distraction in the treatment of ankle osteoarthritis.

OBJECTIVE: Osteoarthritis (OA) is a degenerative disabling joint disease affecting more than 10% of the adult population. No validated disease-modifying treatment is available. Joint distraction is a relatively new approach to the treatment of severe ankle OA. Short-term (3 years) clinical benefit has been proven, but long-term effects remain to be evaluated. METHODS: Patients with severe OA of the tibio-talar joint, who had been treated with Ilizarov joint distraction more than 7 years previously, were included. Pre-treatment data were obtained by retrospective analysis using questionnaires and patients' charts. Post-treatment assessments were undertaken using the same questionnaires and by physical examination. Three approaches were used and results were compared: the van Valburg score, the Ankle Osteoarthritis Scale (AOS), and a patient satisfaction questionnaire. Retrospectively and prospectively obtained data were available from eight patients for comparison. RESULTS: Twenty-five out of 27 patients with severe ankle OA treated with Ilizarov joint distraction could be traced. Appropriate retrospective data could not be obtained from three patients. Six out of the 22 patients (27%) were failures. In 16 patients (73%), significant improvement in all clinical parameters was observed using each of the three approaches. Good correlations were found between the results of the three methods of assessment and retrospectively obtained pre-treatment values were very similar to the prospective data. CONCLUSIONS: In 73% of the patients, significant clinical benefit from joint distraction of severe OA ankles was maintained for at least 7 years. There is, however, a need for further research to try and predict which patients will not respond to this unconventional form of major surgical intervention.